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Gynecologic Oncologist Cervical Cancer Cervical Cancer Cervical 10/11/2018 Gynecologic Gynecologic Oncology Oncologist Endometrial Pre invasive Cancer Surgery vulvar, vaginal, & Uterine Chemotherapy cervical disease Sarcoma Radiation Vulvar Cancer Fallopian Tube Therapy Cervical Cancer Cancer Ovarian Cancer Hormonal GTD Therapy Immunotherapy Cervical Cancer Cervical cancer 14,500 new cases per year in U.S. Etiology and Risk Factors 5,500 deaths Sexual activity Peak age 47 years HPV 16,18,31,33,35 Most common gynecological cancer subtypes world wide Cigarette smoking Immune system alterations Cervical cancer Treatment Depends on stage, disease bulk, patient characteristics & preference Radical pelvic surgery Radiation +/- chemotherapy 1 10/11/2018 Clinical staging of cervical cancer Cervical Cervical cancer Cervical cancer cancer Radiation Therapy Treatment Selection Surgery vs. Radiation Therapy for Stage Advantages Disadvantages Stage I & IIA Disease Applies to all Bladder & bowel Tumor volume patients injury (2-6%) Complicating medical conditions Cure Rate is Equal Survival equal to Vaginal stenosis Known extrapelvic disease (pelvic surgery for early Sexual dysfunction & PA nodal mets stage disease Ovarian failure Age & body habitus Mainly outpatient Delayed therapy complications Endometrial Cervical cancer Cervical cancer Cancer Prognosis Predominately squamous cell histology (85-90%) Viral & venereal association Most common female pelvic malignancy Clinical Stage Definitive diagnosis of microinvasion is made on 40,000 new cases per year Lesion size cone biopsy 7,000 deaths Depth of cervical invasion Microinvasive carcinomas (SGO def) may be Ranks 4th behind lung, breast, & colon Angiolymphatic space treated by less than radical surgery 75% are postmenopausal involvement Stage I thru IIA are equally treated by pelvic radiation or radical surgery 75% are clinical stage I Nodal metastasis 75% overall 5 year survival 2 10/11/2018 Endometrial Cancer Post-menopausal bleeding Peri-menopausal bleeding Irregular pre-menopausal bleeding FIGO Surgical Staging Endometrial Cancer of Endometrial Cancer Role of surgery Definitive treatment (TAH) Stage IA: Tumor limited to endometrium Staging and nodal biopsies / Stage IB: Invasion < 50% of myometrium lymphadenectomy Stage IC: Invasion > 50% of myometrium Control of pelvic disease and hemorrhage Stage IIA: Endocervical gland invovlement Stage IIB: Cervical Stromal involvement FIGO Surgical Staging Vulvar of Cancer Endometrial Cancer Stage IIIA: Tumor invades serosa, adnexa, or 0.3% of all female positive cytology cancers Stage IIIB: Vaginal metastases 3-5% of all female genital Stage IIIC: Mets to pelvic or PA nodes malignancies Stage IVA: Bladder or rectal involvement 85-95% squamous cell Stage IVB: Distant mets, intra-abdominal or inguinal nodes 3,000 new cases per year in U.S. 3 10/11/2018 Vulvar Vulvar The Diagnostic Dilemma Cancer Cancer of the Clinical Presentation Radical vulvectomy, bilateral Itching, soreness, bleeding inguinal / femoral Adnexal Mass Lump or lesion lymphadenectomy Patient delay in seeking Defines extent of disease treatment (stage) Physician delay in making Definitive treatment for most diagnosis patients The Fear of Cancer Adnexal Adnexal Mass Mass Ovarian Masses Non Gynecologic Functional Cysts What is the suspicion of Gynecologic Ovarian malignancy? Uterine Endometriomas Is surgery indicated? Diverticulitis Fallopian Neoplastic Choice of surgical technique & Ileitis Tube incision? Appendicitis Lymphatic Should oncologist be involved? Colon Cancer Pregnancy Pre-operative counseling and Urologic Infectious plan? 4 10/11/2018 Adnexal Mass Ovarian Cancer Ovarian Cancer: Histologic Oncology Consult Suggested Distribution Elevated CA-125, LDH, AFP, HCG Epithelial Complex US findings Germ Cell Premenarchal Stromal Ascites Fixation Carcinomas Prior cancer diagnosis Metastatic Ovarian Germ Cell Ovarian Germ Cell Tumors Tumors 20 - 25% of ovarian neoplasms Benign Most frequent in late teens or early twenties Malignant Fertility concerns Dermoid Dysgerminoma Often present with acute pain Immature teratoma Confused with appy or ectopic Endodermal sinus tumor Chemo sensitive Embryonal carcinoma Almost always unilateral except dysgerminoma Ovarian Stromal Tumors Benign Malignant Fibroma Granulosa cell Thecoma Sarcoma Lydig cell 5 10/11/2018 Epithelial Ovarian Cancer Leading cause of death from Gynecologic cancer 2008 35,000 new cases 16,000 deaths Lifetime risk 1 in 70 5% hereditary Overall 5 year survival 44% Epithelial Ovarian Ovarian Cancer Cancer Signs & Symptoms Age - Primarily postmenopausal Race - Caucasian > Black Early Geography - European Usually no symptoms Reproduction Incidental mass found on routine exam Low Parity Breast feeding Late OCP (protective) Abdominal bloating ERT (no effect) Nausea, Vomiting Bladder and rectal symptoms 6 10/11/2018 Surgery in Ovarian Cancer Definitive Diagnosis Determine Extent of Disease Cytoreduction Second Look Laparotomy Palliation Suspected Ovarian Staging of Ovarian Ovarian Cancer Staging cancer Cancer Pre-operative evaluation Adequate incision Not merely an academic exercise Ultrasound? Aspiration of ascites or four quadrant washings Essential to rational treatment Colonoscopy or BE? planning CT Scan? TAH-BSO Tumor markers? Omental biopsy/omentectomy Prognostic CXR Systematic exploration of all peritoneal Therapeutic Mammogram (>35yrs) surfaces Counseling Retroperitoneal lymph nodes Staging Laparotomy Sites of Metastases in Repeat Staging in Apparent Stage I & II Ovarian Cancer in Early Ovarian Cancer Apparent Initial No. of Stage I &II Ovarian Cancer Stage Patients % Upstaged Re-exploration after initial Laparotomy in “Stage I disease” Diaphragm 8.0% Aortic nodes 18.1% 46% with Grade 3 tumors upstaged Pelvic Nodes 6.0% 34% with Grade 2 tumors upstaged Omentum 8.6% 16% with Grade 1 tumors upstaged Cytology 9.8% Young et al Berek et al 1994 JAMA 250:3072(1983) Young et. al. JAMA 250:3072 (1983) 7 10/11/2018 Survival Stage I/II Ovarian Misstaging of Ovarian Cytoreductive Cancer by Surgeon cancer Surgery Actual DFS General Surgery 65% Survival deficient Physiologic benefits Gyn Oncol 83% 76% Gynecology 48% Enhanced Non Oncol 53% 39% deficient immunologic p<0.05 p<0.03 Gyn Oncology 3% competence deficient Cell growth kinetics McGowen et. Al. Mayer et. Al. Obstet Gynecol 65:568(1985) Gynecol Oncol 47:223(1992) Cytoreductive Surgery Griffiths, CT Natl Cancer Inst Monogr 42:101, 1975 Residual Tumor Size 8 10/11/2018 Radical Cytoreductive Ovarian Cancer: Surgical Surgery Treatment for Advanced in Advanced Ovarian Cancer Disease Significant survival advantage for women Multiple bowel resections optimally cytoreduced Splenectomy Procedures may include: En bloc resection of uterus, ovaries and pelvic Partial Gastrectomy tumor Diaphragm resection Omentectomy Bowel resection Abdominal wall resection Removal of diaphragmatic and peritoneal implants Splenectomy, appendectomy Ovarian Carcinoma Stage IIIC/IV Ovarian Cancer Ovarian Cancer: Importance Prognosis by Stage Variables Determining Survival of Surgeon % 5 yr Survival P value Grade of tumor 0.01 1,866 women with ovarian cancer Size of largest met NS Variables Significant advantage for those >10cm Site of largest women managed by Gynecologic met <10cm 0.004 Oncologist Age Duration of Sx >60yrs More likely to have optimal cytoreduction <60yrs 0.0002 Reduction in death by 25% (p= 0.005) Cytoreductive outcome 0.0001 compared to Ob/Gyn and General Spec. of Surgeon 0.0001 Surgeons Junor et al, Brit J Ob/Gyn, 11/99 Eisenkop Gynecol Oncol 47:1992 National Survey of Ovarian Ovarian Cancer Ovarian Cancer Carcinoma NCI SEER Results I. A Patient Care Evaluation Study of the Reasons for Inadequate American College of Surgeons Surgery Averette et al Cancer 71: Feb 1993 •“10% of women received the care 12,316 patients recommended GYO 21% OBG 45% GS 21% by consensus statement on ovarian cancer” • Unfamiliarity with the disease, treatment, 12-25% had adequate surgery to permit accurate and natural history staging Significant difference in optimal debulking •“43% of women with advanced stage disease • Citation of overall poor prognosis Significant difference in survival (p<0.004) over • Health plans, politics? age 65 received state-of-the-art care” Trimble, E. ASCO 5, 1996 9 10/11/2018 Ovarian Cancer NIH Consensus Recommendations •Patients with high likelihood of ovarian cancer should be given the opportunity of having surgery performed by Gynecologic Oncologist •Aggressive cytoreduction at primary surgery improves long term survival •Completely staged patients with Stage IA or IB, Grade 1 tumors do not require adjuvant chemotherapy •Second look surgery should not be routine •Taxol and a platinum compound is 1st line chemo NIH Consensus Statement 12:1-30, 1994 10 .
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